Document No. 05 (01 Sep 17) Page 1 of 1
Customer: _______________________________ Date Sampled: _______________________Contact Details (new customers or amendments)........................................................
Date Received: ________________________ Address: _____________________________________ Time Received:
_________________________________________________________________Purchase Order:......... ________________________Email: ____________________________________ Sampling Officer: _____________________Tel: _________________ Fax: ________________ ........................................Signature: ......................................................__________________________
Reason for Analysis:
Product Testing Export Testing
Shelf-life Testing Food PoisoningFood Survey Complaint (give
details)
Sample Type: Dairy Products Fish, Crustaceans and Molluscs
Fruit and Fruit Products
Vegetable and Vegetable Products
Mixed Food Meat and Meat Products Poultry and Poultry Products
Other - Specify
Eggs and Egg Products
* Environmental Swab
Food Type Time
SampleID Brand
Batch / UB Code
Source Temp. (°C)
___________________________________________________________________________________Laboratory Use Only Temperature on Receipt: _______°C Job Number: ______________ Registered by: _________
Request for Bacteriological
Analysis of Food
Public Health Laboratory18 St Johns AvenueNEW TOWN Tasmania 7008Phone: (03) 6166 1106Facsimile: (03) 6230 7036Email: [email protected].
Requested Testing Staphylococcus (coagulase +)
* Yeasts and Moulds
Standard Plate Count Bacillus cereus * EnterobacteriaceaeColiforms Salmonella spp. * Clostridium perfringensE. coli Listeria spp. * Campylobacter spp.Vibrio parahaemolyticus Listeria monocytogenes * Other - Specify
* Test is not NATA-accredited
Comments:
___________________________________________________________________________________Laboratory Use Only Temperature on Receipt: _______°C Job Number: ______________ Registered by: _________
